Physician Specialty Differences in Unprofessional Behaviors Observed and Reported by Coworkers

Key Points Question Are there differences by specialty in the proportion of physicians who are identified in safety event reports submitted by coworkers describing unprofessional behaviors? Findings In this cohort study of 35 120 physicians, 9.1% had at least 1 report from a coworker describing unprofessional behavior. Surgeons were most likely to receive a coworker report, and physicians with a pediatric focus were the least likely to receive a report of unprofessional behavior. Meaning Understanding more about the distribution and patterns of unprofessional behaviors in health care that interfere with individual and team performance can support coworker well-being and the ability to deliver safe high-quality care.


Introduction
High-functioning teams in health care, which include physicians, clinical staff, patients, and families, are essential to promote safe health outcomes.Most health care professionals consistently model professionalism toward coworkers, defined as clear communication; respect for patients, colleagues, and established safety practices; commitment to excellent technical care; and integrity. 13][4] Unprofessional behaviors threaten individual and team function 5,6 and increase avoidable patient complications 7 ; individuals who model unprofessional behaviors are associated with well-being concerns 8,9 and increased malpractice claims. 10e Coworker Concern Obversation Reporting System (CORS) program is a national collaborative directed by the Vanderbilt Health Center for Patient and Professional Advocacy (CPPA) at Vanderbilt University Medical Center.A total of 193 participating hospitals and practice sites send electronic safety event reports describing concerns about unprofessional behaviors to CPPA, which uses qualitative coding 11 to identify individual reports of unprofessional behavior as well as individual clinicians with repeated concerns. 2,4Individual reports and patterns of repeated concerns are used to identify clinicians who then receive feedback as a part of tiered interventions designed to promote self-regulation and to reduce reports of unprofessional behavior. 2e CORS program addresses behaviors by physicians, advanced practice clinicians, and nursing professionals.For the purposes of this study, we were interested in focusing on differences among physicians defined by their specialty because of the varying needs of teams that deliver care in different settings defined by physician specialty.Studies describing unprofessional behaviors among physicians toward coworkers have typically included all specialties and have used simulations or other models to identify the impact of unprofessional behavior. 2,3,5,6Limited data are available to understand the distribution and types of unprofessional behaviors among physicians by specialty and the proportion of physicians with repeated professionalism concerns.Understanding more about the distribution and patterns of repeated unprofessional behaviors can offer insight to leaders and organizations in supporting individual and team well-being and delivering safe care.
This study was designed to address the following study questions: what is the distribution of physicians by specialty who have received with reports of perceived unprofessional behaviors, measured through electronic safety reports in CORS?What are the types of concerns described in coworker reports about unprofessional behavior?Are there differences by specialty among physicians who develop apparent patterns of unprofessional behavior as described in CORS reports?

Study Design and Participants
This retrospective cohort study included credentialed physicians (ie, no residents or fellows) in the national CORS collaborative who had at least 1 day of active practice at a CORS site during the study period (January 1, 2018, to December 31, 2022).All physicians were eligible to be identified in a report.Physicians entered the cohort either on the first day of the study period or the physician's first date of employment at an active CORS site, whichever came later.

CORS Data
CORS data for each site are held at Vanderbilt under the terms of business associate agreements in place between each site and Vanderbilt University Medical Center.Each site provides names and practice specialties for credentialed physicians.At each site, reports of coworker concerns about a professional colleague's behavior are entered into the health system's electronic safety event reporting systems by any individual with access to the electronic safety reporting system.
Data are sent to Vanderbilt, and all patient, staff, and professionals' identifiers are removed.
Independent coders review CORS reports and reliably assign reports to various categories defined in previous studies. 2,11Coders assign unique concerns to categories, including clear and respectful communication, professional responsibility, competent medical care, and integrity. 11Coders are tested for reliability every 6 months and are found to have consistent coding 88% to 92% of the time.Reports with statements such as "Dr XX was about to start the bronchoscopy, but I reminded him we needed to do the time out.He mumbled, 'You're a bossy cow'" would be identified as disrespectful communication (eTable 1 in Supplement 1)."The patient was confused and had no idea where he was.I asked Dr YY if we should wait for the patient's spouse to arrive.Dr YY said, 'We'll be here all night if we do that.If you won't sign as a witness, I'll get someone else who will'" includes statements that would be coded to professional responsibility.Reports about medical care might include reports such as "Dr XX removed the patient's foley catheter at the end of the case without wearing gloves… had visible urine on his hands and did not wash them… proceeded to touch things in the operating room and left the room."Reports about integrity would include reports such as, "Dr ZZ billed the visit as a level 5 visit, but I know they only spent 4 minutes with the patient."

Study Outcomes
The outcomes of interest were physicians' total number and categories of CORS reports during the study period. 11Patterns were defined using a proprietary algorithm, which weights CORS reports based on recency and severity, with more recent and more severe reports contributing more than older and less severe reports. 2 Physicians who are associated with CORS reports are supported by a tiered intervention model, including peer-delivered messages for single reports and awareness interventions for those with apparent patterns of reports, in which their status relative to local and national benchmarks is provided to them in an effort to guide self-regulation and improved performance. 2

Study Variables
4][15][16] To assess whether previous findings showing that pediatric-focused clinicians generated fewer professionalism concerns reported by patients might also apply to coworker concerns, 16 physicians whose credentialing files included a pediatric specialty or subspecialty were identified as pediatric focused.Site characteristics included the region of the country and whether the physician's site of

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Physician Specialty and Unprofessional Behaviors Reported by Coworkers practice was academic or community (ie, regional health system or community-based multispecialty group).

Statistical Analysis
We calculated the proportion of physicians in each specialty who received at least 1 report and who qualified for an awareness intervention based on having a pattern of repeated professionalism concerns.Proportions of physicians in each specialty having single reports and those qualifying for awareness interventions were reported with a 95% CI and compared using the Pearson χ 2 test.In addition, the proportion of clinicians receiving at least 1 report of each type was reported by specialty.
Logistic regression was used to calculate odds of any CORS report, adjusting for specialty, region, academic practice status, and pediatric specialty status.Adjusted odds ratios (ORs) with 95% CIs were reported by specialty and by pediatric focus.

Results
The  7 There were 4705 physicians (13.4%) who practiced in pediatric settings.
Surgeons had the smallest proportion of physicians with a pediatric-focused practice (451 [5.5%]).
There were 3179 physicians (9.1%) who were associated with at least 1 CORS report.The proportion of individual physicians named in at least 1 CORS report differed by specialty (Figure 1).1A).For other specialty focus areas, there was no statistically significant difference in the proportion of physicians associated with having at least 1 CORS report between those with a pediatric focus and those with a nonpediatric focus.
In a multivariable logistic regression model controlling for physician and practice site characteristics (Figure 2), all specialty types had significantly higher odds of at least    The most common types of CORS reports for all physician specialties involved clear and respectful communication, followed by professional responsibility (Table 2).The least common type of CORS report involved professional integrity.There was a statistically significant difference between specialties in the proportion having reports for each type of CORS report with nonsurgeon nonproceduralists demonstrating the lowest rate of reports of each type.
There were 338 physicians (1.0%) who had repeated CORS reports that represented a pattern.

Discussion
In this cohort study of 35 120 physicians, 9.1% were associated with at least 1 report about unprofessional behavior by coworkers, meaning that most physicians never received any reports.
The proportion receiving at least 1 CORS report ranged from 5.6% to 13.8% with observed differences by specialty focus.In a multivariate model, physicians who practiced in nonsurgical, nonprocedural-focused specialties were significantly less likely to have CORS reports than the other specialties.Physicians who had a pediatric focus were significantly less likely to be identified in a CORS report than physicians who did not have a pediatric focus.There was an even smaller proportion (<1%) of physicians with a pattern of repeated CORS reports.The proportion of  individuals associated with a pattern in each specialty differed significantly, with surgeons being the group most likely to be associated with a pattern of repeated CORS reports.
Unprofessional behavior observed and described by patients and coworkers has been shown to result in increased risk for patient complications 7,17 and malpractice claims. 17Physicians with repeated professionalism concerns are also likely to have a deleterious impact on culture and team performance. 5,6,17What are ways in which unprofessional behaviors might increase the risk for complications?Exposure to dismissive behaviors has been shown to reduce individual clinician and team performance, often mediated through reduced vigilance, help-seeking, and communication. 5,6dividuals and teams who are more focused on the unprofessional colleague may not pay as much attention to the task at hand or may not speak up if they have concerns about clinical care.In this study, concerns about unprofessional communication were the most common reports and concerns about professional integrity were the least common.The types and frequencies of unprofessional behavior types in this study parallel the distribution seen in previous studies. 3,7,11rgeons were more likely to have at least 1 CORS report of unprofessional behavior and to have patterns of CORS reports than other specialties.9][20] It is possible that surgeons practice in more stressful environments than the other specialties, resulting in interactions during high-stakes events that increased the likelihood of a coworker reporting a concern.In addition, surgeons serve on teams that require interdependence, potentially increasing the frustration for the surgeon or for other members of the team.It is also possible that personality characteristics of surgeons, nurses, and other clinicians who deliver care in perioperative settings differ from clinicians who provide care in other settings.These dynamics could affect both the frequency of unprofessional behaviors and the likelihood that an individual would report the behavior.
Nonsurgeon proceduralists are likely to practice in both procedural areas (ie, endoscopy suites) and inpatient and ambulatory settings, so individual team member's perceptions of unprofessional behavior could be governed by the degree of complexity and stress in those environments.In addition, team-based care for nonsurgeon procedural specialties could introduce additional stresses and tension points that might affect team performance.Emergency medicine physicians were less likely than surgeons and nonsurgeon proceduralists to be associated with a coworker concern.The structure of teams in emergency medicine and the interaction of emergency medicine physicians with multiple professions and specialties introduces unique stresses on team function in that setting.
In addition, care in emergency departments can be stressful and overwhelming at times.Interestingly, physicians who practiced with pediatric-focused privileges were significantly less likely to receive a CORS report even when controlling for specialty and practice setting.There may be a difference in physicians and nurses who choose to practice in pediatrics, possibly reflecting a different temperament or practice style.Overall, however, regardless of specialty, the majority of physicians in this cohort (91% overall) never received any reports of unprofessional behavior during the study period.
The findings of this study have implications for both individual physicians and health care leaders.Understanding more about how different team members in complex health care teams perceive behaviors provides insight into culture, psychological safety, and trust in a variety of settings.Previous studies have demonstrated that physicians with well-being concerns are more likely to be associated with reports of unprofessional behavior. 8,9,21Physicians who develop patterns of unprofessional behavior reports may need an assessment of their well-being.In a similar fashion, if entire groups of physicians begin to receive reports more than other groups, systems issues, culture, or leadership factors should be considered. 22It is worth noting that 86% to 90% of physicians by specialty did not have any CORS reports during the study period.Health care leaders can use these data to underscore the importance of professional accountability in creating optimal patient outcomes and individual and team function. 1,2,17

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Physician Specialty and Unprofessional Behaviors Reported by Coworkers

Figure 1 .
Figure 1.Proportion of Physicians by Specialty and Pediatric Focus Identified in 1 or More Coworker Concern Reports

Figure
Figure 2. Multivariable Analysis of Odds of Receiving a Coworker Concern Report by Specialty and by Pediatric Focus

Figure 3 .
Figure 3. Proportion of Physicians With Repeated Coworker Concern Reports by Specialty 3.0

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Physicians exited the cohort on of the study period or the physician's departure from the site.If a physician moved to another CORS site, only the first site's data were used.
JAMA Network Open.2024;7(6):e2415331.doi:10.1001/jamanetworkopen.2024.15331(Reprinted) June 6, 2024 2/10 Downloaded from jamanetwork.comby guest on 06/08/2024 the last day Two-sided P values of less than .05were considered statistically significant.Sensitivity analyses restricted to physicians with at least 2 years of follow-up (99% of the original cohort) were not materially different than primary models, so analyses reported here include the full cohort.All statistical analyses were performed with R version 4.2.3 (R Project for Statistical Computing) from April 14 to September 8, 2023.

Table 2 .
Types of Coworker Concern Reports Received by Physician Specialty Group a Pearson χ 2 test.